Office Financial Policy
Payment is expected at time of service. We will accept cash, check, or credit card. Checks accepted with valid driver’s license only. There will be a $25 service charge for a returned check.

We accept insurance. We will file your claims at no charge. It is the patient’s responsibility to provide us with current insurance information.

If any payment from an insurance company becomes 30 days past due, you will be immediately billed for the entire balance.

We will file pre-treatment estimates, AT YOUR REQUEST ONLY. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it may delay important dental care.

Not all services are covered by insurance. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Our staff can never guarantee your eligibility and coverage.

Insurance limitations and regulations vary with all insurance plans. Therefore, if your insurance plan denies a service, you will be responsible for the complete charge. We do not base your treatment plan on what your insurance plan covers or doesn’t cover. We are working for you, not the insurance company.

Past due accounts may be turned over to a collection agency. Any fees incurred due to this, will be added to the outstanding balance. This may include late fees, collection agency fees, court fees etc.

Missed Appointment Policy
Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of $25 per hour of the scheduled appointment time.

HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
  2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
  3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
  4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
  5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
  6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
  7. We agree to provide patients with access to their records in accordance with state and federal laws.
  8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
  9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Patient Information

NAME:

LAST NAME
FIRST NAME
MIDDLE INITIAL
PREFERRED NAME

ADDRESS:

STREET
APT NUMBER
CITY
STATE
ZIP
Employer
Birth Date
Driver License
STATUS
Height
Weight
GENDER
PHONE
Home
Social Security Number
Work
Cell
Email

EMERGENCY CONTACT:

Name
Phone
How did you hear about us?
Referred By
Other

Insurance

1 - Primary Dental Carrier:
1 - Insurance Co Name:
1 - Insurance Phone Number:
1 - Insured’s Name:
1 - Birth Date:
1 - ID Number:
1 - Insured’s Employer:
1 - Group Number:
1 - Relationship to Patient:
2 - Secondary Dental Carrier:
2 - Insurance Co Name:
2 - Insurance Phone Number:
2 - Insured’s Name:
2 - Birth Date:
2 - ID Number:
2 - Insured’s Employer:
2 - Group Number:
2 - Relationship to Patient:

If Patient Is Under 18 Years Of Age

Responsible Party Address
Responsible Party - Group Number
Responsible Party - Relation to Patient
Responsible Party - STREET
Responsible Party - CITY
Responsible Party - STATE
Responsible Party - ZIP

The information on this page is correct to the best of my knowledge

PATIENT OR PARENT/GUARDIAN SIGNATURE

Other Information
Physician’s Name
Physician’s Phone
Have you had a serious illness or operation?
If yes, please describe
Are you currently under physician care?
If yes, please describe

Medical History and Information:

Please check those conditions that have ever applied to you

Conditions

Abnormal BleedingAlcohol AbuseAllergiesAnemiaAngina PectorisArthritisArtificial Heart ValveAsthmaBlood TransfusionCancerChemotherapyColitisCongenital Heart DefectDiabetesDifficulty BreathingDrug AbuseEmphysemaEpilepsyFacial SurgeryFainting SpellsFever BlistersFrequent HeadachesGlaucomaHIV+ AidsHeart AttackJoint ReplacementHeart MurmurHeart SurgeryHemophiliaHepatitis AHepatitis BHepatitis CHigh Blood PressureKidney ProblemsLiver DiseaseLow Blood PressureMitral Valve ProlapsePace MakerPsychiatric ProblemsRadiation TherapyRheumatic FeverSeizuresSexually Transmitted DiseaseShinglesSickle Cell DiseaseSinus ProblemsStrokeThyroid ProblemsTuberculosisUlcers

Allergies

AspirinCodeineErythromycinLatexMetalsPenicillin

Other Allergies
Do you Smoke or use Tobacco?

Women Only

Are you taking Birth Control Pills?
Are you pregnant?
Are you nursing?
Please list any medications you are currently taking
Have you EVER taken any bisphosphonates? (e.g. Fosomax, Actonel)

Treatment Authorization

By submitting this form I agree that the information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.
PLEASE CHECK A SOURCE IN WHICH YOU WOULD LIKE TO RECEIVE APPOINTMENT REMINDERS

Email

Text Message
Both Email and Text Message

Email Address

Cell Phone


We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for Tempe Dental Care in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

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